Anne Rossier Markus

Can the deployment of community health workers for the delivery of HIV services represent an effective and sustainable response to health workforce shortages? Results of a multicountry study.

In countries severely affected by HIV/AIDS, shortages of health workers present a major obstacle to scaling up HIV services. Adopting a task shifting approach for the deployment of community health workers (CHWs) represents one strategy for rapid expansion of the health workforce. This study aimed to evaluate the contribution of CHWs with a focus on identifying the critical elements of an enabling environment that can ensure they provide quality services in a manner that is sustainable.The method of work included a collection of primary data in five countries: Brazil, Ethiopia, Malawi, Namibia, and Uganda.The findings show that delegation of specific tasks to cadres of CHWs with limited training can increase access to HIV services, particularly in rural areas and among underserved communities, and can improve the quality of care for HIV. There is also evidence that CHWs can make a significant contribution to the delivery of a wide range of other health services.The findings also show that certain conditions must be observed if CHWs are to contribute to well-functioning and sustainable service delivery. These conditions involve adequate systems integration with significant attention to: political will and commitment; collaborative planning; definition of scope of practice; selection and educational requirements; registration, licensure and certification; recruitment and deployment; adequate and sustainable remuneration; mentoring and supervision including referral system; career path and continuous education; performance evaluation; supply of equipment and commodities.The study concludes that, where there is the necessary support, the potential contribution of CHWs can be optimized and represents a valuable addition to the urgent expansion of human resources for health, and to universal coverage of HIV services.

Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform

BACKGROUND Medicaid is a major source of public health care financing for pregnant women and deliveries in the United States. Starting in 2014, some states will extend Medicaid to thousands of previously uninsured, low-income women. Given this changing landscape, it is important to have a baseline of current levels of Medicaid financing for births in each state. This article aims to 1) provide up-to-date, multiyear data for all states, the District of Columbia, and Puerto Rico and 2) summarize issues of data comparability in view of increased interest in program performance and impact assessment. METHODS We collected 2008-2010 data on Medicaid births from individual state contacts during the winter of 2012-2013, systematically documenting sources and challenges. FINDINGS In 2010, Medicaid financed 45% of all births, an increase of 4% [corrected] in the proportion of all births covered by Medicaid in 2008. Percentages varied among states. Numerous data challenges were found. CONCLUSIONS/IMPLICATIONS FOR RESEARCH AND POLICY Consistent adoption of the 2003 birth certificate in all states would allow the National Center for Health Statistics Natality Detail dataset to serve as a nationally representative source of data for the financing of births in the United States. As states expand coverage to low-income women, women of childbearing age will be able to obtain coverage before and between pregnancies, allowing for access to services that could improve their overall and reproductive health, as well as birth outcomes. Improved birth outcomes could translate into substantial cost savings, because the costs associated with preterm births are estimated to be 10 times greater than those for full-term births.

THE ROLE OF MEDICAID IN PROMOTING ACCESS TO HIGH-QUALITY, HIGH-VALUE MATERNITY CARE

One of the most challenging aspects of health care improvement and reform is ensuring that individuals, particularly those who are vulnerable and low income, have access to care. Just as challenging is the imperative to ensure that the care accessed is of the highest quality possible. The Institute of Medicine (IOM) report, Crossing the Quality Chasm, identified the primary goal of any high-quality heath care system: The ability to furnish the right care, in the right setting, at the right time. This aim must also be the primary goal of Medicaid in regard to providing access to high-quality care for women throughout the reproductive cycle. Nationwide, Medicaid is a large purchaser of maternity care; in 2006, the program paid for 43% of all births and maternity costs represented 29% of all hospital charges to Medicaid. Under current federal law, state Medicaid agencies have to fulfill several obligations related to assessing, ensuring, and improving the quality of care, particularly for enrollees who receive services through managed care arrangements. The main purpose of this article is to analyze and describe the role of Medicaid in facilitating access to care for pregnant women and ensuring high-quality maternity care that is affordable. It first summarizes the federal Medicaid requirements regarding eligibility, coverage of benefits, financing, and service delivery, with a special emphasis on existing quality provisions. Then, it discusses current issues and recommends several Medicaid reforms, particularly in the area of quality assessment and improvement. All reforms, including Medicaid reforms, should seek to support the IOM-identified aims. Much of the emphasis in Medicaid policy development has been focused on access to care and great need for reform remains in the area of quality assurance and improvement, and disparity reduction because the program can play a significant role in this regard as well. More broadly, health care reform may provide an opportunity to revisit key issues around access to and quality of maternity care, including the benefit package, the content of services covered in the package, the frequency with which these services should be furnished, and the development of meaningful measures to capture whether women of childbearing age, including pregnant women, regardless of insurance status, indeed receive efficient, timely, effective, safe, accessible, and woman-centered maternity care.

U.S. civil rights policy and access to health care by minority Americans: implications for a changing health care system.

The history of health care discrimination as well as ongoing, extensive evidence of racial disparities argue for continued vigilance in the area of health care and civil rights. Under Title VI of the Civil Rights Act of 1964, individuals have challenged de facto discriminatory policies adopted by health entities receiving federal financial assistance. Title VI health litigation is difficult because of complex issues of proof as well as confounding problems of poverty and lack of health insurance that affect both claims and remedies. An analysis of cases brought under the law suggests that discrimination claims within a particular market fare better than those challenging decisions to relocate or alter the market served. This has important implications for claims involving discrimination by managed care organizations. Because the same potential for discrimination exists in the new health system of managed care, although in altered form, data collection and evaluation are warranted.

Adoption of health center performance measures and national benchmarks.

This study examines the adaptability of standardized performance measurement tools in 3 community-based health centers. Although health centers have considerable experience in the area of performance reporting, they do not currently participate in a national reporting system that is transparent and standardized. The analysis of the data collected from health centers indicates that not only can these safety net providers readily integrate standardized measures, the quality of care being provided compare favorably to national benchmarks. With evidence of solid performance may come the types of financial adjustments essential to permitting health centers to move more decisively into the broader private health insurance markets that may exist in their service areas.

Examining the association between Medicaid coverage and preterm births using 2010–2013 National Vital Statistics Birth Data

ABSTRACT Reducing the number of preterm births is a high public health priority in the U.S. Preterm birth, affecting an estimated 380,000 infants annually, is a leading cause of infant mortality and morbidity and is associated with individual and systemic characteristics. Preterm birth is estimated to cost society

Maternity Leave Access and Health: A Systematic Narrative Review and Conceptual Framework Development

26 billion annually. Despite an elevated financial burden caused by preterm birth, very little is known about who bears these costs. This study seeks to understand the relationship between Medicaid and private insurance payment for preterm birth, using multiple years of vital statistics data, which for the first time since 2010 include information on payment source. The nationwide data cover births that occur in all settings, including non-hospital settings, and many maternal characteristics not available in other datasets, improving upon previous analyses. These data can be used to promote better Medicaid coverage of interventions known to be effective in reducing preterm births.

Defining and Determining Medical Necessity in Medicaid Managed Care

Background Maternity leave is integral to postpartum maternal and child health, providing necessary time to heal and bond following birth. However, the relationship between maternity leave and health outcomes has not been formally and comprehensively assessed to guide public health research and policy in this area. This review aims to address this gap by investigating both the correlates of maternity leave utilization in the US and the related health benefits for mother and child. Methods We searched the peer-reviewed scholarly literature using six databases for the years 1990 to early 2015 and identified 37 studies to be included in the review. We extracted key data for each of the included studies and assessed study quality using the “Weight of the Evidence” approach. Results The literature generally confirms a positive, though limited correlation between maternity leave coverage and utilization. Likewise, longer maternity leaves are associated with improved breastfeeding intentions and rates of initiation, duration and predominance as well as improved maternal mental health and early childhood outcomes. However, the literature points to important disparities in access to maternity leave that carry over into health outcomes, such as breastfeeding. Synthesis We present a conceptual framework synthesizing what is known to date related to maternity leave access and health outcomes.

Effectiveness of Evidence-Based Asthma Interventions

OBJECTIVES: In 2013, the American Academy of Pediatrics published a policy statement calling for pediatricians to be informed about the need for specific pediatric medical necessity language because children deserve “the intent embedded in Medicaid.” This study aims to explore the definitions and determinations of medical necessity in Medicaid Managed Care (MMC), document the relevant language used throughout Medicaid, and investigate whether the federal standard of medical necessity for children is replicated in related state documents. METHODS: We conducted a desk review of state statutes, model MMC contracts, and 2 provider manuals per state, for 33 states with a full-risk MMC model. RESULTS: The federal “to correct and ameliorate” standard was replicated in 100% of state regulations, 72% of MMC model contracts (n = 13 of 18 MMC model contracts available online), and 54% of provider manuals (n = 30 of 56 available and sampled online). Only 9 states had an explicit “preventive” pediatric medical necessity standard in their state regulations that exemplified “the intent imbedded in Medicaid.” CONCLUSIONS: The federal medical necessity standard for children is not replicated consistently within MMC programs from the state, to health plans, to network providers. Although the majority of the documents reviewed included the standard, the presence of the standard decreased by almost half between state-level and network-provider-level regulations. Having a single, explicitly defined pediatric medical necessity definition replicated at all levels of the health system would reduce confusion and increase the ability of pediatricians to apply the standard more uniformly.

The impact of publicly financed family planning services on pregnancies, births and costs: a critical review of the peer-reviewed literature

This study assessed the effectiveness of translating evidence-based asthma interventions into community health centers. BACKGROUND AND OBJECTIVES: Researchers often struggle with the gap between efficacy and effectiveness in clinical research. To bridge this gap, the Community Healthcare for Asthma Management and Prevention of Symptoms (CHAMPS) study adapted an efficacious, randomized controlled trial that resulted in evidence-based asthma interventions in community health centers. METHODS: Children (aged 5–12 years; N = 590) with moderate to severe asthma were enrolled from 3 intervention and 3 geographically/capacity-matched control sites in high-risk, low-income communities located in Arizona, Michigan, and Puerto Rico. The asthma intervention was tailored to the participant’s allergen sensitivity and exposure, and it comprised 4 visits over the course of 1 year. Study visits were documented and monitored prospectively via electronic data capture. Asthma symptoms and health care utilization were evaluated at baseline, and at 6 and 12 months. RESULTS: A total of 314 intervention children and 276 control children were enrolled in the study. Allergen sensitivity testing (96%) and home environmental assessments (89%) were performed on the majority of intervention children. Overall study activity completion (eg, intervention visits, clinical assessments) was 70%. Overall and individual site participant symptom days in the previous 4 weeks were significantly reduced compared with control findings (control, change of −2.28; intervention, change of −3.27; difference, −0.99; P < .001), and this result was consistent with changes found in the rigorous evidence-based interventions. CONCLUSIONS: Evidence-based interventions can be successfully adapted into primary care settings that serve impoverished, high-risk populations, reducing the morbidity of asthma in these high-need populations.